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Hormonal effects on the fetus and neonate

This month both the leading article and controversy sections of the journal contain reviews of endocrine topics. Long a neglected area in neonatology, these reviews remind us of the importance of the hypothalamo-pituitary-adrenal axis for health. Brook introduces the contentious topic of treating a pregnant woman known to be carrying a fetus affected with congenital adrenal hyperplasia with high dose dexamethasone, in order to avoid virilisation of her female fetus (pageF176). Although the treatment works, there is a high cost, and information on the long term effects is sparse. Hughes and Kelnar continue the thought provoking debate (pages 178-181). As ever, there is a need for more experience and large scale studies, which will be difficult to achieve.

The message about the effectiveness of antenatal steroids in reducing the mortality from RDS can hardly have failed to penetrate the minds of the most recalcitrant colleagues; but more is not necessarily better. The tendency to give multiple courses of antenatal steroids on the basis that “one is good so two must be better” worries many of us. Ng reviews the literature on the fetal HPA axis, reminding us that programming effects on the fetus can have a lifelong influence (pageF250).

Away from the HPA axis, Dembinski and colleagues (page F215) remind us that iodine containing compounds can have remarkable effects on thyroid function in very premature babies. A significant dose of iodine is contained within the single injection of contrast medium used to opacify a long line, and this can be reduced by using the non-ionic iodinated agent iopromide.

Doppler ultrasound in the vena cava and ductus

Neonatologists continue to reach the parts that a stethoscope cannot reach with a Doppler ultrasound probe. This month, different teams from Australia report on Doppler studies. The research group in Sydney (pages 182-194) measured flow measurements in the superior vena cava, which turned out to be lower in very preterm babies with large ductal shunts, more of whom went on to develop intraventricular haemorrhage. In Melbourne, Doppler ultrasound was used to analyse the difference in velocity of flow between the two ends of a patent ductus in order to assess the degree of left-to-right shunt (page F195). The method seemed to work but as yet there is no clinical application for the technique.

Group B streptococcus in Bedford

Early onset GBS remains a hot topic (page F205), and the RCPCH Specialty neonatal group, the BAPM, are assisting a multidisciplinary working party led from the PHLS who are attempting to devise guidelines suitable for use in the UK. These guidelines were recently circulated to BAPM members for comment. In Atlanta, USA there has been a decline of 65% in the incidence of early onset GBS, from 1.7 to 0.6 per 1000 births following the introduction of the CDC guidelines (Schraget al NEJM 2000;342:15–20). It is disappointing to read in this issue that the incidence in Bedford in the 1990s was 1.15 per 1000. No local policy was in place at the time, and the authors rightly call for more studies of the incidence in the UK. A BPSU study has begun (see commentary on page F207) and deserves our full support.

Infant mortality in Malawi

While paediatricians in Bedford are worrying about GBS rates of 1.15 per 1000, it is sobering to read that the infant mortality in Malawi is 136 per 1000 (page F200). Although HIV infection is important in this part of sub-Saharan Africa, it was not the main cause of death. Prematurity and being born between May and July were also important.

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